Dumbor L. Ngaage

Blood transfusion adversely affects the outcome of coronary artery bypass grafting (CABG), yet blood transfusion after CABG is still common. Total arterial revascularisation (TAR) is increasingly used in current practice but its impact on postoperative blood transfusion is not known. We reviewed the cardiothoracic and blood bank databases and collected data for isolated primary CABG patients from July 2007 to June 2012, excluding patients who had a single graft (n = 148). Perioperative variables of TAR patients (n = 745) were compared with patients who had one or more venous grafts (SVG, n = 1,761) for first-time isolated CABG. The conduits used in TAR patients were predominantly left internal thoracic and radial arteries. Matched group comparison of TAR and SVG patients was performed. The association of TAR with blood transfusion was investigated using multivariate and matched analysis. Of 2,506 patients, the 745 (29.7 %) that had TAR were generally younger, with less complex coronary artery disease and less often diabetic. After correcting for these by 1:1 matching, the mean chest tube drainage and rates of blood transfusion remained significantly lower (p < .0001) in TAR patients. Indeed, red cells, platelets and fresh frozen plasma were significantly less frequently transfused in TAR patients. By multivariate analysis, TAR had an independent effect on reducing blood transfusion after CABG [odds ratio (OR) 0.67, 95 % confidence interval (CI) 0.47–0.97, p = .03]. TAR achieved predominantly with left internal thoracic and radial arteries substantially reduced blood transfusion rates after primary CABG. Further studies are warranted.

The aim of this paper was to compare the clinical impact of the different myocardial protection strategies in coronary artery bypass grafting (CABG) patients to facilitate decision-making for use of on- or off-pump technique. Prospectively collected data for primary CABG patients between April 1, 1996 and December 30, 2010 (N.=8779) were analyzed. Early adverse cardiac and cerebrovascular events (ACCE) and late survival were compared between on-pump; cardioplegia (CPA, N.=3862, 44%), cross-clamp fibrillation (XCF, N.=3751, 43%), and off-pump (N.=1166, 13%) myocardial protection. Second, clinical profiling for the risk of ACCE with each strategy was performed using principal component analysis. Finally, a 1:1 matched cohort comparison of 1055 patients was done. There were vast differences in baseline characteristics between groups. Significantly fewer grafts per patient were constructed using off-pump. There were no remarkable differences in operative mortality and 10-year survival rates between the groups after restrictive matching. Principal component analysis identified high risk profiles; factor 1 (ejection fraction 30-50%, prior myocardial infarction, non-elective operation), and factors 4 (hypertension, hypercholesterolemia, Body Mass Index >30 kg/m2) and 5 (female, octogenarian, left main stem disease) to be strongly associated with ACCE after on-pump CABG while lower risk profiles; factors 5 and 6 (extracardiac arteriopathy, prior stroke) were associated with ACCE after off-pump CABG. Comparatively, on-pump techniques were associated with greater risk of adverse events in "high risk" patients defined by clinical characteristics, while off-pump was associated with increased risk of adverse events in "low risk" patients.

The optimal timing of coronary artery bypass grafting (CABG) after myocardial infarction (MI) is still controversial. With advances in perioperative care and myocardial protection, CABG is not infrequently undertaken sooner. Although CABG soon after MI is associated with high morbidity and mortality, the impact of CABG timing on late survival is not clear. We analysed prospectively collected data for 8320 patients who underwent primary CABG from 1996 through 2010. Operative outcomes and late survival were compared between patient categories based on MI-to-CABG days: groups A (0–30, n = 658), B (31–60, n = 734), C (>90, n = 2698) and D (no MI, n = 4230). The effect of the timing of surgery on survival was determined using multivariate and Kaplan–Meier analyses. As the MI-to-CABG interval increased, the frequency of urgent/emergency operations decreased and hospital mortality (A, 3.5% vs B, 2.6% vs C, 1.2%, vs D, 1.1%, P < 0.0001) steadily declined. In general, patients who had CABG within 90 days of MI had more cardiac morbidity and co-morbidities. Expectedly, therefore, postoperative organ system dysfunction (cardiac, renal, respiratory and neurological) was more frequent in these groups. Reoperation for bleeding was similar for all groups, but blood product transfusion decreased as the MI-to-CABG days increased. The 10-year survival improved with the MI-to-CABG interval (A, 72.2% vs B, 73.4% vs C, 75.8% vs D, 81.4%, P < 0.0001). By multivariate analysis, the MI-to-CABG interval was not a risk factor for operative or late mortality. However, less frequent were left internal mammary artery use, non-elective surgery and high blood transfusion rates; all more often associated with shorter MI-to-CABG intervals. Early and late mortality risk for CABG declines with increasing interval from MI for reasons indirectly linked to the timing of surgery. Our findings emphasize the importance of preoperative organ system optimization and consistent left internal mammary artery use, regardless of the proximity of surgery to MI or the exigency of surgery.

Temporary renal replacement therapy (RRT) facilitates recovery from a major perioperative renal injury and, although RRT can improve the hospital outcome, it is not known as to whether it mitigates long-term renal sequelae. Therefore, we investigated the risk of long-term dialysis after RRT post-cardiac surgery. We analysed prospectively the data collected for all hospital survivors who received RRT following cardiac surgery between March 1996 and July 2010, excluding those on dialysis preoperatively or with a functioning renal transplant. The follow-up data were obtained for all surviving patients. The mean age of the 82 patients was 68.6 ± 9.9 years, and 60 (73%) were male. Severe pre-existing renal dysfunction with a serum creatinine level of >200 μmol/l was present in 15 (18%) patients and diabetes in 31 (38%) patients. Operative procedures included redo surgery (n = 11, 13%) and thoracic aortic surgery (n = 9, 11%). During a 13.4-year follow-up, there were 38 late deaths. Only three patients with severe preoperative renal dysfunction received dialysis. The Kaplan–Meier 5- and 7-year survival rates for this patient cohort were 54% and 38%, respectively. In conclusion, a major renal insult requiring temporary RRT after cardiac surgery does not increase the risk for renal dialysis in the long term for patients with normal renal function preoperatively.

Patients with Addison's disease undergoing cardiac surgery are at risk of developing a crisis. There is no consensus on the preoperative and intraoperative management of this group of patients undergoing cardiac surgery so the recommendations for non-cardiac patients are often used. The consensus statement from the international task force of the American College of Critical Care medicine recommends 100 mg of intravenous hydrocortisone for patients with adrenal insufficiency in septic shock, but in patients undergoing surgery, especially with extracorporeal circulation, the dosage may even be higher. We report our management of a patient with well-controlled adrenal insufficiency for 30 years who developed intraoperative Addisonian crisis despite the recommended preoperative corticosteroid supplementation. The importance of adequate corticosteroid supplementation for cardiac surgery patients, adapting the surgical strategy to allow for optimal management of potential complications and close monitoring with heightened awareness are discussed.

Congestive heart failure complicating aortic valve disease has been reported to increase the operative mortality associated with aortic valve replacement. To determine whether this adverse effect remains late after aortic valve replacement, we analyzed prospectively collected and survival data of 849 patients who underwent aortic valve replacement between 1999 and 2008. There were 243 (29%) cases of heart failure preoperatively (138 current and 105 prior). Both operative and late mortality rates (up to 10 years) were significantly higher in heart failure patients. Current congestive heart failure caused a 3-fold increase in operative mortality and an 86% increase in late mortality, whereas previous history of heart failure caused a doubling of late mortality. Preoperative heart failure still compromises early and late survival after aortic valve replacement. Surgery should be considered early in patients with aortic valve disease and deferred, when possible, in those with frank heart failure.

The November 2009 issue of the European Journal of Cardiothoracic Surgery features interesting discussions about the European System for Operative Risk Evaluation (EuroSCORE). The papers by Ranucci and colleagues [1] and Nissinen and colleagues [2] rightly highlight the limitations of EuroSCORE and suggest methods for improvement based on their institutional experiences, and they should be congratulated. More interesting, however, are the erudite accompanying editorial comments by Dewey and Herbert [3] and Nashef [4], which adequately address issues raised in the papers and the poignant editorial by Manasse [5]. There is a consensus that the EuroSCORE needs to be revised or, more appropriately, updated, and the process has been initiated. The EuroSCORE has served us well and proved to be reliable. Rather than re-package an ‘out-of-date’ system to make it appear contemporarily germane, as some of the authors have suggested, the ongoing EuroSCORE project to update the risk stratification model should be enthusiastically supported. Its main advantage, which is the simplicity and bedside applicability, should not be lost in the new form.